INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone/buprenorphine monitoring inspection conducted on January 10, 2023 through January 11, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Northeast Treatment Centers, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure that all counselors met the educational and/or experiential qualifications in one of four applicable personnel records reviewed.
Employee #9 was hired as a counselor on October 10, 2022. The employee has a bachelor ' s degree in English, which is not a qualifying degree for the position of counselor.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/18/23, the recruiting department within Human Resources was educated on the employment requirements for counselors to be within the guidelines. The recruiting team was given a list of the guidelines that will be used as a checklist to complete the onboarding process. Moving forward, the onboarding process will focus on the outlined requirements and ensure that all staff have the experience and educational background. Part of the recruiting process will also include providing the hiring manager a copy of the employee's transcript during the onboarding process to ensure the educational requirements are met. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, the facility failed to provide a counselor assistant, who has a high school diploma or GED equivalent, with direct observation by a trained counselor or clinical supervisor while counseling clients for the first 3 months of employment in one of four applicable personnel record reviewed.
Employee #14 was hired as a counselor assistant on August 5, 2022. The personnel record showed the counselor assistant had a client caseload as of August 26, 2022, with weekly individual clinical supervision; however, there was no documentation that direct observation was conducted during the employee ' s first 3 months of employment.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Moving forward, when the counselor assistant begins employment, the clinical supervisor will assign the counselor assistant to a counselor during their first 3 months of employment to engage in direct observation of clinical services being conducted by the counselor. The counselor will be made aware of the counselor assistant's requirements and the purpose of the observations. The Counselor Assistant will then meet with the clinical supervisor to discuss their observations and provide education during weekly supervision.
Due to the time frame of employee #14's hire date, we are unable to correct the licensing alert. Moving forward, the above-mentioned plan of correction will be implemented effective 2/6/23. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to ensure that staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases, and other health related topics within the regulatory timeframe in one of four applicable personnel records reviewed.
Employee #13 was initially hired as a counselor on August 23, 2021, but the employee's position changed to a counselor assistant on January 10, 2022. The employee was due to receive the minimum of six hours of HIV/AIDS training and four hours of TB/STD training no later than August 23, 2022; however, there was no documentation in the record that the HIV/AIDS training and the TB/STD training was completed at the time of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employee #13 will have the minimum 6 hours of HIV/AIDS training and 4 hours of TB/STD Training no later than 4/30/23. We will continue to monitor the DDAP website for upcoming trainings and will assign employee #13 to complete both above mentioned trainings when they become available.
Moving forward, during the onboarding process the designated hiring manager will request all available training certificates. During the new-hire's orientation week, the clinical supervisor and program manager will determine which of the mandatory DDAP training have not yet been completed. These trainings will be scheduled as soon as they become available to ensure that all mandatory trainings are completed within 1 year of employment. |
705.22 (1) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a physical plant inspection conducted on January 11, 2023, the facility failed to maintain all structures on the grounds of the facility so as to be free from any danger to health and safety.
At the time of the inspection, the client restroom, located on the first floor of the facility, had a broken panel exposing an electrical box, which allowed for a possible electrical shock hazard for the clients and staff.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/11/23 the facilities maintenance staff had repaired the panel and will continue to monitor and maintain all structures on the grounds to ensure the facility is free from endangering the health and safety of our staff and clients. Maintenance staff will conduct weekly inspections to ensure the grounds of the facility are safe and maintained properly. |
705.29 (2) (iii) LICENSURE Child care.
705.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(2) Interior space. The nonresidential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on a physical plant inspection conducted on January 11, 2023, the facility failed to maintain protective caps over each electrical outlet for a facility that provides custodial care.
There were two outlets, both located in the child-care room, that did not have protective caps allowing for possible electrical shock hazard at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/11/23 The facilities maintenance staff replaced the protective caps over each of the electrical outlets that were missing in the child-care room. The childcare staff will monitor the outlets daily and communicate to the facilities maintenance staff if the caps appear broken or missing. On 1/11/23, signs have been posted near the electrical outlets to remind all staff to recover the outlets if removed for use. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their own written procedures for the management of treatment/rehabilitation services for clients in three of nine client records reviewed.
The facility policy and procedure manual stated that the comprehensive treatment plan is to be completed within 15 days of admission. Additionally, the facility policy and procedure manual stated that an aftercare plan will be completed within a week of discharge. Also, the facility policy and procedure manual stated that a discharge summary is to be documented within 24 hours of discharge and that follow-up contact is to be documented within 30 days of discharge.
Client #1 was admitted on September 16, 2022 and was active at the time of inspection. The comprehensive treatment plan was due to be completed no later than October 1, 2022, per facility policy; however, the treatment plan was completed on November 9, 2022.
Client #5 was admitted on August 10, 2021 and was discharged on November 16, 2022. The discharge summary was due no later than November 17, 2022, per facility policy; however, the summary was completed on January 9, 2023.
Client #6 was admitted on November 11, 2021 and was discharged on October 11, 2022. The aftercare plan was due to be completed by October 11, 2022, per facility policy; however, the plan was completed on January 3, 2023. Also, the discharge summary was due to be completed no later than October 12, 2022, per facility policy; however, the summary was completed on January 3, 2023. Additionally, follow-up information/contact was due to be completed no later than November 11, 2022 per facility policy; however, follow-up contact was documented on January 3, 2023.
This is a repeat citation from the July 28, 2022 provisional license follow-up inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
During the intake process, after the intake assessment is completed, the client will be assigned their counselor and will begin attending services. The counselor will schedule a time to meet with their client to complete the comprehensive treatment plan. The clinical supervisor will monitor the completion of comprehensive treatment plans by auditing and reviewing weekly caseload reports that are completed by the QA team. Clinical supervisors will meet with their counselors during supervision to review outstanding treatment plans. If comprehensive plans are not completed in the required time frame, the counselor will be placed on success plans.
Upon discharge, the clinical staff will be informed that their former patient has been discharged. At that time, they will be instructed to complete the discharge summary form group in Credible. They will be given a time frame of 5 business days to complete the documentation. The clinical supervisor will monitor their productivity and review progress during weekly supervisions.
This plan will be implemented 2/13/23. |
709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in two of nine client records reviewed.
Client #5 was admitted on August 10, 2021 and was discharged on November 16, 2022. There was a release of information form to another treatment provider that was signed and dated by the witness on September 29, 2022; however, the dated signature of the client was not documented on the release form.
Client #9 was admitted on August 30, 2022 and was active at the time of inspection. There were release of information forms to a funding source and a urinalysis laboratory that were signed and dated by the witness on August 30, 2022; however, the dated signature of the client was not documented on either release form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff will be retrained on confidentiality on 2/9/23 to follow the 709.28 guidelines regarding obtaining a dated signature on a release of information form.
Effective 2/6/23, All release of information forms will be reviewed and signed by the clinical supervisors and program manager to confirm they have been completed correctly and in its entirety.
There will be ongoing monitoring to ensure compliance through monthly audits.
Client #5 has been discharged since 11/16/22, therefore is unable to sign the release of information.
Client #9 has been suspended since 1/29/22, therefore is unable to sign the release of information. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of the facility's August 2022 through January 2023 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following a physical or sexual assault by staff or client.
Two physical assault incidents, occurring on August 13, 2022 and October 11, 2022, were not reported to the Department as of the date of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The senior Director will continue to monitor the programs compliance with the timely completion of unusual incidents being filed within 3 business days following the incident. The program manager and clinical supervisors will participate in a refresher training on the criteria of what is considered a critical incident. This training will take place during the weekly management team meeting on 3/6/23. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the facility failed to document the completion of a random urinalysis at least monthly in one of eight applicable patient records reviewed.
Patient #1 was admitted on September 16, 2022 and was active at the time of inspection. There was no documented drug screen urinalysis, in the record, for the month November 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Senior Director will work in conjunction with the nursing team to ensure that all random monthly urinalysis sent to Atlantic Diagnostic Labs are reflected each monthly in SMART. Senior Director will meet with Atlantic Diagnostic Labs on 2/13/23 to address their error in failing to input the urinalysis results into SMART and how to prevent future errors. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide an average of 2.5 hours of psychotherapy services per month during a patient's first 2 years, 1 hour of which shall be individual psychotherapy, in five of six applicable patient records reviewed.
Patient #1 was admitted on September 16, 2022 and was still active at the time of the inspection. The record of service and progress notes documented that during the month of December 2022, there was 1 hour and 30 minutes of psychotherapy.
Patient #2 was admitted on September 29, 2022 and was still active at the time of the inspection. The record of service and progress notes documented that during the month of October 2022, there was 1 hour and 30 minutes of psychotherapy.
Patient #5 was admitted on August 10, 2021 and was discharged on November 16, 2022. The record of service and progress notes documented that during the month of September 2022, there was 3 hours of group and no individual hours of psychotherapy.
Patient #8 was admitted on August 4, 2021 and was discharged on November 13, 2022. The record of service and progress notes documented that during the month of October 2022, there was 2 hours and 30 minutes of group and no individual hours of psychotherapy.
Patient #9 was admitted on August 30, 2022 and was active at the time of the inspection. The record of service and progress notes documented that during the month of September 2022, there was 1 hour and 30 minutes of group and no individual hours of psychotherapy. Additionally, the record of service and progress notes documented that during the month of October 2022, there was 4 hours and 30 minutes of group and no individual hours of psychotherapy.
This is a repeat citation from the July 28, 2022 provisional license follow-up inspection and the January 20, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program manager, clinical supervisor, and counselor receive a weekly caseload report from the QI department for each counselor's caseload. The counselor will utilize this report to place holds on their patients to encourage their participation and to ensure they are receiving the hourly requirement for their current level of care. At the end of each week, the program manager and supervisors will follow-up
with each counselor on their caseload and place holds to discuss compliance expectations with any client that did not complete their weekly requirement. The program plans to be in compliance by 3/6/23. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to ensure the annual evaluation of the patient ' s status, completed by the patient ' s counselor, was reviewed, dated, and signed by the medical director in three of four applicable patient records reviewed.
Patient #3 was admitted on October 29, 2018 and was active at the time of inspection. The annual evaluation of the patient ' s status was completed by the counselor on November 16, 2022; however, the evaluation was not reviewed, dated, and signed by the medical director.
Patient #5 was admitted on August 10, 2021 and was discharged on November 16, 2022. The annual evaluation of the patient's status was completed by the counselor on September 2, 2022; however, the evaluation was reviewed, dated, and signed by the medical director, after discharge, on December 16, 2022.
Patient #8 was admitted on August 4, 2021 and was discharged on November 13, 2022. The annual evaluation of the patient's status was completed by the counselor on November 11, 2022; however, the evaluation was not reviewed, dated, and signed by the medical director.
This is a repeat citation from the July 28, 2022 provisional license follow-up inspection and from the January 20, 2022 and December 11, 2020 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor and Program manager will continue to audit the caseload reports weekly to review the annuals that are due for each patient in that current month. The QA team will continue sending the caseloads reports on a weekly basis and will highlight the annuals that are due that month. The clinical supervisor and program manager will audit the completed annuals on a weekly basis and ensure that all annuals are completed for that month. The QA supervisor will monitor compliance and work with the clinical supervisor and program manager to inform on any non-compliance with timely completion.
Effective 2/6/23, once annuals are completed, QA supervisor will inform the medical director of completed annuals that are ready for review and signature on a weekly basis. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on review of client records, the facility failed to include documentation, during the intake and admission process, of a psychosocial evaluation in three of four applicable client records reviewed.
Client #1 was admitted on September 16, 2022 and was active at the time of inspection. There was no psychosocial evaluation documented in the record at the time of the inspection.
Client #2 was admitted on September 29, 2022 and was active at the time of inspection. There was no psychosocial evaluation documented in the record at the time of the inspection.
Client #9 was admitted on August 30, 2022 and was active at the time of inspection. There was no psychosocial evaluation documented in the record at the time of the inspection. inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Since 8/25/22, the primary counselor was responsible for completing the biopsychosocial with all new admissions assigned to their caseload. Effective 2/6/23, the responsibility will return to the Intake Department which includes two intake counselors and the intake supervisor. The restructuring of the process will allow the intake counselor to complete the biopsychosocial with the new admit during the intake process.
This process will continue to be monitored by utilizing the BI report to monitor the completion of the biopsychosocial from the patient's chart. If a patient has a missing biopsychosocial, they will be notified to meet with the intake counselor within 24 hours to be scheduled.
Client #1 is unable to have his biopsychosocial completed at this time due to being suspended since 1/20/23. However, if he returns within 30 days from 1/20/23, a biopsychosocial will be completed upon his reinstatement to the program.
Client #2 is unable to have her biopsychosocial completed at this time due to being suspended since 11/24/22.
Client #9 is unable to have his biopsychosocial completed at this time due to being suspended since 1/29/23. However, if he returns within 30 days from 1/29/23, a biopsychosocial will be completed upon his reinstatement to the program. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan, which is to be developed with the client, in two of four applicable client records reviewed.
Client #2 was admitted on September 29, 2022 and was active at the time of inspection. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection.
Client #9 was admitted on August 30, 2022 and was active at the time of inspection. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to client #2 and Client #9 being suspended at this time, we are unable to complete their treatment plans. If they return within 30 days of their suspension, they will be re-assigned counselors and will complete their treatment plan at that time.
Clinical Supervisors and program managers will review the weekly caseload report for each counselor. Any past due treatment plans will be discussed during supervisors and given a time frame to complete the plan. Repeated failure to complete treatment plans on time, and failure to meet deadlines given will result in a success plan. This plan will be implemented on 2/6/23. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every sixty days in five of seven applicable client records reviewed.
Client #1 was admitted on November 9, 2022 and was active at the time of inspection. The comprehensive treatment plan was completed on November 9, 2022, and the first update was due no later than January 9, 2022; however, the update was not completed as of the date of inspection.
Client #3 was admitted on October 29, 2018 and was active at the time of inspection. A treatment plan update was completed on October 31, 2022, and the next update was due no later than December 31, 2022; however, the update was not completed at the time of inspection.
Client #5 was admitted on August 10, 2021 and was discharged on November 16, 2022. A treatment plan update was completed on August 8, 2022, and the next update was due no later than October 8, 2022; however, the update was not completed prior to discharge.
Client #6 was admitted on November 11, 2021 and was discharged on October 15, 2022. The comprehensive treatment plan was completed on December 23, 2021. There were no treatment plan updates completed prior to discharge.
Client #8 was admitted on August 4, 2021 and was discharged on November 13, 2022. A treatment plan update was completed on September 1, 2022, and the next update was due no later than November 1, 2022; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The leadership team will continue to monitor and retrain the clinical staff on completing treatment plan updates correctly and within the required time frames. This will begin 2/6/23 and will occur during supervisions and clinical staff meetings.
Client #1 is currently suspended; therefore, we are unable to complete the treatment plan update.
Client #3 had a session with her primary counselor on 1/7/23 and had completed her treatment plan update during that session.
Client #5 has been transferred and is now discharged from the program; therefore, a treatment plan update cannot be completed.
Client #6 has been transferred and is now discharged from the program; therefore, a treatment plan update cannot be completed.
Client #8 has been discharged from the program; therefore, a treatment plan update cannot be completed. |
709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include a discharge summary, in one of three applicable client records reviewed.
Client #4 was admitted on January 17, 2012 and was discharged on September 29, 2022. There was no discharge summary documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #4 discharge summary will be completed by 2/10/2023.
At the time of discharge, the leadership team will be made aware of the discharges and reason for their discharge. The counselor of the discharged patient will be informed that their patient has been discharged and the reason. The clinical supervisor and program manager will inform each counselor to complete the discharge form group within 5 business days. The QA team will assist with monitoring the completion of discharges using their tracking system. The QA supervisor will inform the clinical supervisor and program manager of any discharges that have not yet been completed.
This plan will be implemented by 2/6/23. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include follow-up information, in one of three applicable client records reviewed.
Client #4 was admitted on January 17, 2012 and was discharged on September 29, 2022. There was no follow-up information regarding the patient documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/29/22, A note was placed in Credible regarding Client #4, who made a statement about his decision to not return to the program. At that time, Client #4 was administratively discharged per his request.
Effective 2/6/23, a staff member has been assigned to completing follow-ups on a weekly basis for all patients that have not had contact prior to discharging them. Once the individual is discharged, the assigned counselor will complete the discharge form group, which includes a follow-up contact form.
Effective 2/6/23 The QA department will work in conjunction with the clinical supervisor and program manager to provide feedback on follow-up that have not been completed. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of administrative documents, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to ensure an annual evaluation of the patient's status was completed by the patient's counselor and reviewed, dated, and signed by the medical director was submitted and approved by the Department for the December 11, 2020 and January 20, 2022 annual licensing inspections, and for the July 28, 2022 provisional license follow-up inspection. Failing to ensure an annual evaluation of the patient's status was completed by the patient's counselor and was reviewed, dated, and signed by the medical director was again found to be a deficiency in the January 10, 2023 through January 11, 2023 annual licensing inspection.
A plan of correction for failing to ensure 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment was submitted and approved by the Department for the July 28, 2022 provisional license follow-up inspection and the January 20, 2022 annual licensing inspection. Failing to ensure 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment was again found to be a deficiency in the January 10, 2023 through January 11, 2023 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 2/6/23, the clinical supervisors and program manager will continue to monitor the weekly caseload reports for each counselor provided by the QA department. This will highlight the patients that are currently demonstrating non-compliance with their required weekly and monthly treatment hours. These requirements will also be discussed during supervisions and clinical staff meetings to emphasize the importance of patient's receiving and meeting their minimum monthly requirement. At the end of each week, the program manager and clinical supervisors will review each counselor's caseload and place holds on those who have not completed services for that week. |